Professional Documents
Culture Documents
left ear
left ear
yes
3. Nose
a.Drainage -yes
b.Blockages
-c.Sense of Smell-d.Congestion -yes
e.Mucous Membranes--
accom
contacts lenses
right ear
right ear
no
no
yes
yes
none
none
no
no
no
moist
pink
4. Throat/Mouth
a.Mucous Membranes -moist
pink
pale
b.Oral Hygiene-teeth
dentures good
c.Swallowing -easy
difficult
painful
d.Lymph nodes-normal
enlarged
pale
pallor
pallor
poor
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
______________________________
Neuro
1 . L O C - alert
2.Orientation3. Mood
confused
4. Communication 5. Motor Function 6.Glasgow Coma Scale
Eye Opening Response
Verbal Response
coma
time
angry
partial
partial
4pt
3pts
2pt
None
1pt
Oriented
5pt
4pt
Incomprehensible speech
None
Motor Response
3pt
2pt
1pt
6pt
5pt
4pt
3pt
2pt
None
1pt
Total=
____________
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
______________________________
Integument
1 . C o l o r pink/ jaundice /pallor/ ashen/ dusky erythema cyanotic
aprop to race
2.Hair Distribution-even
uneven
3 . M o i s t u r e - wet
moist
dry clammy
4.Temperature-hot
warm
cool
cold
5.Texture -smooth
rough
6.Turgor -____ seconds
7.Vascularity-high
normal
low
8 . E d e m a
- none
little
yes
location: _________________
9 . L e s i o n s - no
yes
location: ______________shape: _____________
type: ______________color:
_______________
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
________________________________________________
_____________________ ____________________________________________
________________________
Chest/Thoracic
1. C a r d i a c
a . A / P
( S 2dub) -- clearly audible
muffled
murmur
gallops
b . E r b s P t - - clearly
audible
muffled
murmur
gallops
c . T / M ( S 1lub)--- clearly
audible
muffled
murmur gallops
d . H e a r t B e a t - regular
irregular
e.Apical rate ___________________
f.Apical Rhythm-regular
irregular
g.PMI located
-yes ___________ no_______________
h . C a p r e f i l l _ _ _ _ _ _ seconds
brisk
rapid
sluggish
2 Respiratory
a.Breath Sounds --
Anterior: clear
wheezes
crackles
Posterior; clear
wheezes
crackles
b . R e s p i r a t i o n rate: _____
even reg irreg
labored
shallow
deep
c . C h e s t E x p a n s i o n - - symmetrical
unsymmetrical
d . C o u g h - no
yes
non-productive
productive color:_________
amount: ___________
.
yes
no
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
_______
GI/Abdomen
1.Inspection: flat
round
2.Bowel Sounds:
x4 active hyperactive hypoactive faint absent
RLQ :
RUQ :
active
active
hyperactive
hyperactive
hypoactive
hypoactive
faint
faint
absent
absent
LUQ :
LLQ :
active
active
hyperactive
hyperactive
3 . P a l p a t i o n
:
4 . D i e t
:
5.Toleration of diet:
6.Change in appetite:
7.Recent weight change:
8.NG/GT tube:
hypoactive
hypoactive
faint
faint
absent
absent
Special Notes:
________________________________________________________ _________
______________________________________________________________ ___
__________________________________________________________________
__ _______________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________________
Elimination
1 . U r i n e :
continent
incontinent
clear cloudy
yellow
amber bloody tea-colored foul smelling
diapers
catheter
2.Last BM: _________ how often:___________ brown
yellow
tarry green
watery
soft
hard
formed
diarrhea
black
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
______
Musculo-Skeletal
1 . R O M : Upper extremities :full partial active passive
assistive
Lower extremities:
full partial active passive
assistive
2.Strength
Upper extremities
1+
2+
3+
4+
Lower extremities
1+ 2+
3+
4+
3 . P u l s e s :
radial :
1+
2+
3+
4+
dorsalis pedis:
1+
2+
3+ 4+
4 . G a i t :
steady/balanced unsteady/unbalanced limping shuffled
5 . P o s t u r e :
straight
slumped
6 . A m b u l a t e s :
w/o assistance w/ assistance
crutches walker
cane
wheelchair
7.History of falls:
no
yes
how often: _______________
8.Ability to perform ADLs:
yes
no
9 . E d e m a :
no
yes
location: _____________
10.Abnormalities:
no
yes
description: _________________________________
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
_________________ ________________________________________________
_______________________ _____
%IBM/BMI
Height: __ ___lbs.Weight: ____ _ _in.BMI: _ _ _____ %IBM: ______%
BMI:weight / (height) x 705
Less than 18.5underweight
25.9 29.9overweight
18.5 24.9normal weight
30 or above=
obese
%IBM: